Different Surgical Procedures Of Peroral Endoscopic Myotomy And Pneumatic Dilation For Achalasia

Background and Objective:Achalasia(AC)is a primary motor disorder of the esophagus characterized by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis.The fundamental cause of this condition remains unknown[1].Before the development of peroral endoscopicmyotomy(POEM),pneumatic dilation(PD)is considered to be the most effective therapy for AC,because of its simple operation,low treatment cost,and short hospital stay.The short-term effect of POEM is encouraging,and it is reported that it cured AC in thousands of patients.Because of its advantages of minimal invasiveness,safety and effectiveness,it has been widely adopted around the world.At present,there are circular myotomy the muscularis propria and full-thickness.The comparison of the advantages of these two kinds of incision is seldom reported.The length of the cut is also different.In order to ensure the curative effect,recommended incision length is 80 to 100 mm.Csendes,et a1[2] pointed out that because the tension of LES can increase no more than 40 mm,the incision length of esophageal cardiac muscle layer should be 60 mm or less in Heller operation.Therefore,we believe that the POEM operation may also obtain the same effect by adopting short incision.In this study,we compare the clinical efficacy between circular myotomy and full-thickness myotomy,between the operations adopting incision of ?5 cm and that of > 5 cm,and between POEM and PD,to demonstrate the advantages and disadvantages of POEM and PD to provide rationale for clinical treatment of AC.Methods:First,we collected data of 56 achalasia patients who were treated with POEM in our hospital from February 2013 to August 2014.Of these patients,24 were assigned to the circular myotomy group,and 32 to the full-thickness group;28 were assigned to the group with an incision of ?5 cm were in the short-myotomy,and 28 to the group with an incision of> 5 cm were in the long-myotomy.We compared degree of symptom relief in the four groups,and observed the change in esophageal diameter after operation and intraoperative and postoperative incidences of complications.According to the statistical analysis of different indexes,corresponding clinical conclusions.We also collected data of 86 achalasia patients who were treated with POEM or PD in our hospital from February 2011 to September 2014.Of them,56 were assigned to the POEM group and 30 to the PD group.We observed and compared the symptom relief after the operation,change in esophageal diameter,incidences of intraoperative and postoperative complications,length of hospital stay,and hospitalization expenses of the two groups.According to the statistical analysis of the results,conclusing this clinical trial.Results:Before the treatment,no significant difference was found in the general information between the circular myotomy and full-thickness groups,and between the groups with an incision of ?5 cm and > 5 cm(P>0.05).Preoperative Eckardt score was significantly different from that at months 1,6 and 12 in the four groups after the operation(P < 0.05).We can see that at months 1,6 and 12 after the operation?esophageal diameter was the largest at the 6th month after the operation,and no significant difference existed in intraoperative and postoperative gas complication(P?0.05).The Eckardt score was significantly changed at months 1,6 and 12 after the operation in both POEM and PD groups.Eckardt score at months 1 and 6 after operation was not significantly different.In POEM group,the largest esophageal diameter at 6 month narrowed more obviously.At 12 month,Eckardt score decreased more greatly.The efficiency was higher after 1 year,but the occurrence of gas complications and hospitalization cost was also higher,and hospital stay was longer.Conclusions:1.The short-term clinical curative effect and the occurrence of intraoperative and postoperative gas complication are similar after the operation adopting circular myotomy or full-thickness,and incision of ?5 cm or > 5 cm.Whether adopting long-myotomy or shortmyotomy,It indicates that cutting off the thickening esophageal muscle layer and cardiac narrow ring in POEM surgery is the key to successful operation.circular myotomy and full-thickness both are effective,if circular myotomy keeping outer membrane or serous intact can achieve the same clinical efficacy and reduce complications.2.For AC patients treated by POEM,circular myotomy and incision of ?5 is a better choice,which can reduce the body damage degree and is in the best interests of the patients.3.For short-term treatment,POEM and PD both are effective,but the curative effect of POEM is better and lasts longer.4.Compared with POEM,PD has a wider range of indications.It has the advantages of simple operation,lower complication occurrence,shorter hospital stay and lower cost.